Healthcare Provider Details

I. General information

NPI: 1285740225
Provider Name (Legal Business Name): REBECCA GRIMAUD-CHILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KIM AVE STE 4
TUNKHANNOCK PA
18657-9101
US

IV. Provider business mailing address

1 KIM AVE STE 4
TUNKHANNOCK PA
18657-9101
US

V. Phone/Fax

Practice location:
  • Phone: 570-836-4400
  • Fax: 570-836-4440
Mailing address:
  • Phone: 570-836-4400
  • Fax: 570-836-4440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD419150
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier378679000
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: